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7/31/2019 0

EHRs: The Good, the Bad, and the Ugly

Graham Billingham, MD, FACEP, FAAEM, Chief Medical Officer, MedPro Group

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Identify patient safety and malpractice risks associated with electronic health record (EHR) implementation, use, and maintenance

Discuss strategies and best practices to ensure safe patient care and an effective, efficient, and defensible medical record

Explain how an EHR system can be used to improve patient safety and outcomes and mitigate risk

Understand the current litigation environment of EHRs and forensic audits

Understand emerging risks for the future

Overview

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Handwriting

Dictation

Template: T-System

Boutique: Ibex, Picis

Enterprise: EPIC, Cerner

Aftermarket products

mHealth — apps

FHIR - next generation

EHR evolution

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EHR goals

Source

Increase practice efficiencies and cost savings

Improve care coordination

Improve accuracy of diagnoses and health outcomes

Increase patients’ participation in their care

Improve quality and convenience of patient care

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Certified EHRs support patient safety efforts

Improved aggregation, analysis, and communication

Evidence-based diagnostic decision support.

Therapeutic decision support

Prevention of adverse events.

Clinical alerts and reminders.

Data reports to support performance improvement activities

Use of EHRs for clinical quality improvement research.

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Improve Communication during PACU Handoffs and Increase Nurse Satisfaction

Use of a standardized checklist in the electronic health record (EHR) increased both the accuracy and amount of information exchanged during handoffs from anesthesia to post-anesthesia care units (PACUs)

The checklist also decreased the time it took to conduct a verbal handoff and increased nurse satisfaction

The use of a standardized anesthesia to PACU EMR-based handoff checklist significantly increased the percent of accurate information transferred without considerably affecting the duration of the PACU handoff process

Source: ECRI 7/3/19; Journal of PeriAnesthesia Nursing Volume 34, Issue 3, June 2019, Pages 622-632

Recent literature - EHR checklist

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Data from the 2012 and 2013 Medicare Patient Safety Monitoring System.

The sample included patients age 18 and older that were hospitalized for one of 3 conditions: acute cardiovascular disease, pneumonia, or conditions requiring surgery.

Outcome measures were in-hospital adverse events, including hospital-acquired infections, adverse drug events (based on selected medications), general events, and post-procedural events.

Among the 45,235 patients who were at risk for 347,281 adverse events in the study sample, the occurrence rate of adverse events was 2.3%, and 13.0% of patients were exposed to a fully electronic EHR.

Patients exposed to fully electronic health records, however, had 17–30 percent lower odds of any adverse event

Cardiovascular, pneumonia, and surgery patients exposed to a fully electronic EHR were less likely to experience in-hospital adverse events.

Source: https://www.ncbi.nlm.nih.gov/pubmed/26854418; J Patient Saf. 2016 Feb 6. Electronic Health Record Adoption and Rates of In-hospital Adverse Events. Furukawa MF1, Eldridge N, Wang Y, Metersky M.

AHRQ Study: Fully Electronic Health Record Associated With Lower Odds of In-Hospital Adverse Events

Recent literature - reduction in adverse events

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Recent literature – mixed results

1246 hospitals over 7 years

EHR implementation, EHR vendor, and Meaningful Use status

Looked at CHF, pneumonia, AMI

Process care measures improved 45%

No difference in mortality rate

No difference in readmission rate

Source: https://www.ncbi.nlm.nih.gov/pubmed/31233144



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Federal incentive programs beginning in 2009.

To date, these initiatives have provided over $37 billion in incentive payments to clinicians and hospitals to adopt health information technology, including EHRs.

Use of EHRs in office-based practice has grown from about 24 percent to 86 percent in 2017.

The growth of EHRs in hospitals is even more dramatic; in 2017, 96 percent of non-Federal acute care hospitals used an EHR.

Source: retrieved from

https://www.bostonglobe.com/news/nation/2014/07/19;

https://www.ahrq.gov/news/blog/ahrqviews/promise-of-electronic-health-records.html

AHRQ

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Death By 1,000 Clicks – Fortune 3/18/19

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Death By 1,000 Clicks – Fortune 3/18/19

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Streamline care transitions

Decrease cost

Reduce handoffs

Drug-drug interactions

Evidence-based guidelines

Narrow practice variation

Measure outcomes

Clinical decision support

Disease management

“Hub-and-spoke” problem

User interface

Disenfranchised physicians

Workflow disruption

Patient safety errors

Time away from patients

Vicarious liability

De-installations/AR lag

Few winners as of yet

EHRs: Is the glass half full or half empty?

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Excessive physician and staff time to implement

Disruption to practice

Concern with the time it will take to implement and be eligible for meaningful use

Concern with staff skills and ability to implement

Unexpected costs for associated hardware

Unexpected costs to implement the basic system

Concern of system quality

Concern with vendor quality and support

Unexpected costs to customize the system to a practice’s needs and requirements

Unexpected costs to maintain the system and keep it function

Source: Terry, K. (2015, May). EHRs broken promise. Medical Economics

Retrieved from http://medicaleconomics.modernmedicine.com/medical-economics/news/ehrs-broken-promise?page=full

Top EHR implementation challenges

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EHRs are used by 93 percent of practices.

EHRs not designed to support quality improvement or research.

Practices typically need ongoing support to navigate the learning curve, adjust their workflows, and improve efficiency.

Few practices are using EHRs to report clinical quality measures. This represents a substantial missed opportunity to drive practice improvement.

One-third of practices have never discussed their data as a team.

Only 63 percent shared patient health data electronically with other providers or organizations.

Practices often are unclear where to turn for technical assistance

Source: Bob McNellis M.P.H., P.A. 2/12/19, AHRQ The Promise of Electronic Health Records: Are We There Yet?

The Promise of Electronic Health Records: Are We There Yet?

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System interface issues — hardware, software applications, data flow (e.g., between order entry and pharmacy)

Clinician communication pitfalls, including problems sending and receiving referral/consult information, as well as possible uncertainty as to whether the information was received

Overuse or inappropriate use of the “copy and paste” function

Alert fatigue, which may cause clinicians to ignore or workaround critical alerts

Process lapses, such as failure to review information for content and accuracy prior to finalizing documentation

System failure and backup processes

EHR Risks

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Role of the EHR in patient safety events

3,099 reports related to EHR

10% classified as “unsafe” condition

15 reports in “temporary” harm

• Entering wrong medication data

• Administering the wrong medication

• Ignoring a documented allergy

• Failure to enter lab tests

• Failure to document an allergy

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A multimillion-dollar "go-live" implementation of the EpicCare EMR from Epic Systems Corp. came under intense scrutiny Tuesday when two nurses approached the governing body of a California hospital with patient safety concerns.

Those concerns stem from an incident at a Contra Costa County hospital clinic at the West County Detention Facility in Richmond, CA, where one nurse says the Epic system's recommended dosage of a heart medication "could have killed the patient."

"We're unable to document our medication administration correctly," said an emotional Lee Ann Fagan, speaking to the Contra Costa County Board of Supervisors in Martinez, CA.

Scott Mace, for HealthLeaders Media , August 16, 2012

CA Nurses Sound Alarm Over Epic EMR System

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Patient harm

Signs of fraud “updcoding”

Gaps in interoperability

Doctor burnout

Web of secrets

Source: https://www.c-span.org/video/?460228-6/washington-journal-fred-schulte-discusses-electronic-medical-record-regulations

Source: https://khn.org/news/death-by-a-thousand-clicks/

Kaiser Health News June 2019

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Burnout among health care professionals is ubiquitous

102 Google Scholar articles

50-70% attribute cause to EHR

Increased patient safety incidents

Increased medical errors

Reduced patient satisfaction

Poorer quality and safety ratings

Increased malpractice risk

Burnout & EHR

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Errors Happen Regularly

Everyone Has Responsibilities

10 year anniversary HITECH Act

21st Century Cures Act; Sec. 3009A. Electronic Health Record Reporting Program

Letter to congress

https://ehrseewhatwemean.org/letter-to-congress/

https://ehrseewhatwemean.org/

Abstract

Four healthcare systems (2 Epic and 2 Cerner).

Six clinical scenarios.

Imaging, laboratory, and medication tasks

There was wide variability in task completion time, clicks, and error rates.

For certain tasks, there were an average of a nine-fold difference in time and eight-fold difference in clicks

Error rates varied by task (X-ray 16.7% to 25%, MRI: 0 to 10%, Lactate: 0% to 14.3%, Tylenol: 0 to 30%; Taper: 16.7% to 50%).

Source: Journal of the American Medical Informatics Association, Volume 25, Issue 9, September 2018, Pages 1197–1201,

MedStar Health National Center for Human Factors in Healthcare



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Recent Court Cases

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53% of participants have already seen EHR-related claims

The top trends:

Cut-and-paste practices

Failure to review additional electronic records

Failure to interface with other systems

Allegations of HIPAA violations

Templates used by EHRs

Too generic

Not intuitive to use

Overreliance on the system

PIAA — EHR litigation data

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EHR errors as a risk factor — by location

Source: CRICO Strategies. (2013, January). Electronic health record pilot project.

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Malpractice risks

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Malpractice risks

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EHR errors as a risk factor — by case type


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Malpractice risk

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Incorrect information in the EHR was a factor in 20% of cases

Faulty data entry - a patient’s height is 60 inches but is recorded as

60 centimeters, which distorts her body mass

Unexpected conversions - the data is entered correctly, but the computer auto-converts it without the user noticing. For example, 2.5 changes to 25, which becomes a medication error when a clinician acts on the higher number.

Wrong file or field - user accidentally opens up the wrong patient file and orders medication or records vital signs for someone else.

Repetitive errors - mistakes in a patient record persist for years without being caught.

EHR Claims Analysis

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EHR errors — by clinical severity outcome


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A legal EHR is an official record of patient care, with specified content and required by regulation.

Develop a policy statement that defines what your practice considers to be a legal patient record.

When is the record considered complete for accreditation/compliance purposes?

How long can it remain incomplete? Complete before release?

What “version” (considering amendments, etc.) is supplied and what visual clues to other versions? Who has access to what versions?

What time span will be applied to each version?

Retention periods? Scanned documents?

Know what the printed copy of the legal EHR record looks like.

Defining the legal EHR

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Time synchronization

Audit trails/metadata

Medical guidelines and best practices are not updated

Alert fatigue/overload

Too many “normal” indicators

Abnormal areas are incorrectly documented

Usable information is harder to find

Document events before they actually occur

Data entered for the wrong patient

Other problem areas

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In 2006, e-discovery amendments were made to the Federal Rules of Civil Procedure.

o Require production of electronically stored data and metadata if requested.

Metadata is the “hidden data”

Such as: author of the entry, timestamp, changes to the record, etc.).

Metadata may not be easily accessible.

o May include requests for email.

Risk strategy discussion:

o Maintenance, retention, and destruction of records

Remember that every keystroke is

in memory by time and author,

even if erased or overwritten.

Electronic discovery

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Hall v. Flannery

o Allowed audit trail over defense objections of peer review protection and privileged content

o Using metadata to establish physician habits and routine

o Access to original displays

o Two different printed versions

o Allegation that the record had been altered

o Software patches and upgrades

o Costly forensic battles

o Designed to be used in the electronic environment

EHR audit trails

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The printed record shows the current information, but not the information that was available to the provider at the time the care was rendered.

Physician documents patient care 4 hours after actual treatment, but the system records the entry as occurring at the time of treatment

The time sequence indicated that a child was born before the C-section was performed.

Plaintiff’s attorney “How much time did you spend looking at the results?”

2 years ago the patient had his foot amputated, but the ROS and the PE indicate that the extremities are normal.

Meta Data — Examples



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26 y/o smoker with fever, flu-like symptoms, pulse ox normal, WBC 14

CXR was read normal per ED

No preliminary reading in EHR

Radiologist dx’d LLL pneumonia 45 min later

Prior to patient discharge

Admitted next day for respiratory failure and ultimately died

RadiologistFailure to properly communicate

Failure to follow critical result protocol

HospitalNegligent hiring, training, and supervision of physicians and nurses

Failure to enforce protocols for communicating radiology results

Negligence in providing medical care (allowing patient to be discharged on the initial ED presentation)

ED attending and residentFailure to diagnose and treat pneumonia

Failure to report chest X-ray findings on the radiology information system in order for the radiologist to determine whether a discrepancy report should be filed.

Case #1 x-ray discrepancy

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37 y/o with HTN, headache, vomiting, blurred vision in right eye resolved by next day

Nurse notes “dysconjugate gaze with right eye.”

ED doc normal exam; dx migraine

Returns confused with aneurysm rupture, now G tube

EHR refreshes every 34 minutes; ED doc never saw notation

Nurses comments went to flow sheet not into notes section

ED docs don’t routinely review the flow sheet

Docs and nurses see and use different screens

Case #2 different screens

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A patient’s orthodontist referred her to an oral surgeon for elective extraction of several teeth. The surgeon met with the patient to discuss the procedure and obtain consent.

The night before the extraction, the surgeon reviewed the patient’s electronic record, and the procedure commenced the next day without complications. However, following the procedure, the surgeon noticed a separate paper chart for the patient.

In the chart was a letter from the orthodontist with a new, updated treatment plan that was never entered into the EHR. The new plan recommended removal of different teeth than the original plan specified.

Case #3 paper to electronic conversion

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A patient who had a history of smoking, high cholesterol, and borderline hypertension presented to his primary care office complaining of intermittent numbness in his left hand and mild neck pain.

The patient expressed concern that his symptoms were cardiac related because his brother had recently had a heart attack. The patient’s electrocardiogram was normal, and the provider diagnosed the patient with nerve compression.

Several months later, the patient presented to urgent care for gout and an ongoing cough. Although the urgent care provider had access to the patient’s electronic record, it did not reflect his recent symptoms or family history of heart attack because it was a duplicate of an older record. The patient was given medication for gout and cough and sent on his way.

Nine days later, the patient was found dead. The death certificate indicated atherosclerotic disease and heart attack as the cause of death.

Case #4 copy and paste



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Identify a workflow process that needs to be adjusted.

Chart the steps in the process, and determine where the pain points exist and possible solutions.

Determine whether to phase in workflow adjustments or implement them simultaneously

Continue to refine efficiency and workflows based on the accumulating experience with the EHR system.

Consult outside experts, but with caution. Your EHR vendor, for example, knows their system better than how your practice works. When it comes to workflow, no one knows your processes better than your staff.

Tips to improve EHR workflow processes

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Consider quarterly report of amended records and daily/weekly report of open records

Billing/coding audits

Practice management

Patient population profiling

Frequently used drugs/supplies

Reconciliation of test results

Status of incomplete charts

Amendments (number and kind)

Release of PHI and HIPAA compliance

Performance improvement: audits and high-risk metrics

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Lost data

Transition

Hybrid systems

System failures

System processes — e.g., test/consult results

Process/workflow changes — new error pathways

Stringent documentation guidelines — no workarounds

Be careful with ‘ghost charts’

Documentation

Overreliance on templates and “check boxes” — the disappearing narrative

Array of patient data not conducive to critical thinking

Implementation/maintenance strategies

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Assessment and comparison of findings from previous visits (problem list)

Known or suspected allergies (alerts)

Medication list/reconciliation (alerts)

Documentation should reflect critical thinking and treatment plan

Documentation risks and strategies

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Abnormal vital signs

Changes in patient’s condition

Response to treatment

Additions/deletions

Late entries

Omissions/incomplete records

Inconsistent/contradictory entries

Subjective remarks/finger-pointing

Medical decision making

Changes in treatment plans

Patient response to a course of treatment

Conversations with the patient

Follow-up care provided

Patient compliance, including missed/cancelled appointments

After hours contact

Consults

Documentation risks and strategies: red flags

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Omission in history

Assessing risk factors

Inadequate exam

Appropriate testing (medical necessity)

Response to therapy

Serial exams

High risk cases – intoxication, AMS, hostile, AMA

Contemporaneous documentation

Pertinent positives and negatives

Prior episodes

Exclude high risk diagnoses

Change in status

Differential diagnoses

Discussions with consultants

Specific discharge instructions

Discrepancies between providers must be addressed

Common Documentation Errors

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Discharged to whom

Specific discharge instructions

Medications-dosage, frequency, duration

Pre-printed

Language specific

Specific time frame and MD referral

Last chance to get it right

Disposition

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Identify functions within the EHR that create high risk for your practice, such as:

Test tracking

Drug interaction and allergy alerts

Cancelled appointments and “no shows”

Medication prescribing process

Consider developing a performance improvement plan to help mitigate these risks.

Source: http://www.healthit.gov/safer/safer-guides

EHR risk strategies

Conduct regular audits

Test system security

Print five charts of high risk diagnoses each quarter and review

Be wary of auto-populate, shortcuts, cloning, drop- downs

Review scribe charting process

Review vendor contract and “hold harmless” clause

Be careful with customization

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Check the patient ID

Document conversations, even online communications, into the patient record

Review and update allergies prior to entering any medication orders

For children, if not built into the EHR, use weight based dosing recommendations, age appropriate dosing calculators, dose range checking, and pedi-specific drug-to-drug interaction

If your institution’s EHR process does not facilitate both cancellation and acknowledgment of receipt of orders for labs, radiology, and pharmacy, then make sure to close this loop

Be aware of, and use when appropriate, clinician decision support (CDS) tools in the EHR.

Minimize the use of free text for order entry.

Be aware of the measurement system the EHR uses (U.S. Customary Units vs. Metric System).

Make sure that the data you enter hasn’t been automatically converted to incorrect data.

Make sure you enter information into the correct field.

Source: https://www.rmf.harvard.edu/Clinician-Resources/Newsletter-and-Publication/2014/Insight-Tips-When-Using-EHRs

CRICO EHR Risk Tips

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Next generation

FHIR® — Fast Healthcare Interoperability Resources

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No one is going back to paper

User interface and workflow integration remain challenging

EHR takes time away from bedside

Work arounds are dangerous

Do not turn off alerts

Marked increase in use of scribes

Many near misses and patient safety events

EHR-related cases are now in the courts

Plaintiffs going after metadata and audit trails

Doctors need to define their legal record

Need to practice for disaster recovery

Still searching for the Holy Grail

Conclusions

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HealthLeaders Media News. (2016, June 3). Only 4% of hospitals don’t use EHRs. Retrieved from www.healthleadersmedia.com/innovation/only-4-hospitals-dont-use-ehrs

Office of the National Coordinator for Health Information Technology. (2016, December). Office-based physician electronic health record adoption. Health IT Quick-Stat #50. Retrieved from https://dashboard.healthit.gov/quickstats/pages/physician-ehr-adoption-trends.php

PIAA. (2015, January). Part 1 of 2: Electronic health records and a summary analysis on the 2012 PIAA EHR Survey. Research Notes, 1(1), 3.

CRICO Strategies. (2017, September 12). CBS educational webinar: EHR-related risks.

Office of the National Coordinator for Health Information Technology. (2018). Electronic health records (Section 1). In Health IT playbook. Retrieved from www.healthit.gov/playbook/

Mangalmurti, S. S., Murtagh, L., & Mello, M. M. (2010). Medical malpractice liability in the age of electronic health records. The New England Journal of Medicine, 363(21), 2060–2067.

Resources

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Frellick, M. (2016, March 16). Note bloat disrupts utility of electronic health records. Medscape. Retrieved from www.medscape.com/viewarticle/860459

ECRI Institute. (2015, October). Copy/paste: Prevalence, problems, and best practices. Retrieved from www.ecri.org/Resources/HIT/HTAIS_Copy_Paste_Report.pdf

Dimick, C. (2008, June). Documentation bad habits: Shortcuts in electronic records pose risk. Journal of AHIMA, 79(6), 40–43. Retrieved from http://library.ahima.org/xpedio/groups/public/documents/ahima/bok1_038463.hcsp?dDocName=bok1_038463

Partnership for Health IT Patient Safety. (2016, February). Health IT safe practices: Toolkit for the safe use of copy and paste. Retrieved from www.ecri.org/resource-center/Pages/HIT-Safe-Practices.aspx

Broulliard, C. P. (2016, August). Electronic health record liability. For the Defense, 80-86.

Resources

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Canfield, D. (2012, March). An overview of state e-discovery rules. Inside Counsel.Retrieved from www.insidecounsel.com/2012/03/15/an-overview-of-state-e-discovery-rules

Mangalmurti, et al. Medical malpractice liability. Sterling, R. B. (2016, March 25). Hidden malpractice dangers in your EHR. Medscape. Retrieved from www.medscape.com/viewarticle/857727

Agency for Healthcare Research and Quality. (2017, June). Patient safety primer: Alert fatigue. Retrieved from https://psnet.ahrq.gov/primers/primer/28/alert-fatigue

Smith, K. (2013, March 5). For doctors, too much information? Politico. Retrieved from www.politico.com/story/2013/03/electronic-alert-glut-overloads-doctors-88394.html; Rice, C. (2013, March 5). 87% of physicians says quantity of EHR alerts ‘excessive.’ HealthLeaders Media. Retrieved from www.healthleadersmedia.com/content/TEC-289789/87-of-Physicians-Say-Quantity-of-EHR-Alerts-Excessive

Luthra, S. (2016, June 15). Screen flashes and pop-up reminders: ‘Alert fatigue’ spreads through medicine. Kaiser Health News. Retrieved from https://khn.org/news/screen-flashes-and-pop-up-reminders-alert-fatigue-spreads-through-medicine/

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